Photo Credit: Liubomyr Vorona

A new American Gastroenterological Association practice guideline provides strategies to reduce high rates of pouchitis after ileal pouch-anal anastomosis.

Pouchitis is the most common complication after ileal pouch-anal anastomosis (IPAA), according to a retrospective cohort study published in the American Journal of Gastroenterology. New guidance from the American Gastroenterological Association (AGA) aims to help clinicians manage the burden effectively.

According to the retrospective cohort study, pouch inflammatory conditions are common, and 14% of patients require advanced therapies following IPAA.

The AGA guideline, researchers noted in Gastroenterology, provides clinicians with “a comprehensive, patient-centered approach to the management of patients with pouchitis and other inflammatory conditions of the pouch.”

Edward L. Barnes, MD, MPH, an author on both the study and the guideline, talked with Physician’s Weekly (PW) about this work and its potential impact on patient care.

PW: Why was it important to do this study?

Dr. Barnes: Much of our understanding of the natural history after IPAA and the epidemiology of pouch-related disorders has been gained through evaluations of selected cohorts or single-center evaluations. These efforts have laid the foundation for our care of patients after IPAA; however, this evaluation of outcomes in a large multi-institutional research network allowed for more generalizable estimates across healthcare systems and networks.

What are the most important findings?

The fact that 14% of patients require advanced therapy after IPAA when most patients have surgery for refractory ulcerative colitis (where our best medications didn’t work) is quite important.

This is a longitudinal analysis of a large database from the US, an approach in studying pouch-related disorders that has been limited in the past. The ability to study trends in the overall epidemiology of pouch-related disorders is important, but perhaps more importantly, understanding the burden of these disorders on patients and the healthcare system is a key finding.

Did the results surprise you?

Some results were surprising, but many confirmed what we suspected and why we sought to perform the study. For example, the fact that we demonstrated that 10% of patients are diagnosed with Crohn’ s-like disease of the pouch within 10 years of IPAA further confirms prior incidence estimates from a meta-analysis that identified the incidence of Crohn’ s-like disease of the pouch at approximately 10% after IPAA. Having confirmation in a different study design and setting is important. 

How could the findings affect patient care?

First and foremost, these findings should inform our practice that pouch inflammatory conditions are common and that the burden of chronic pouch inflammatory conditions, in particular, remains an issue. Early recognition of these issues after IPAA may inform care practices and promote further research to improve outcomes after IPAA.

What questions remain unanswered?

Given the burden of disease identified in this study, multiple questions come to mind. First, we need to better understand the drivers of pouchitis and inflammatory conditions of the pouch in the hopes of potentially decreasing the incidence trends identified in this study and others. This improved understanding of the etiology of pouchitis and inflammatory conditions of the pouch could improve our ability to study methods to prevent these pouch-related disorders.

This study highlights something we often see in clinical practice: Patients with UC who undergo colectomy and an IPAA may have already experienced a difficult disease course with medically refractory UC or UC-related neoplasia. Thus, the burden of these inflammatory complications after IPAA is even more substantial. Improving our understanding of pouch inflammatory conditions and offering early intervention remains a major goal for our research team and in our clinical practice.

What is the potential impact of the AGA guideline?

It is critical to focus on standardizing our approach to managing patients after IPAA. In the 2024 AGA guideline on pouchitis and inflammatory pouch disorder management, we tried to focus on pragmatic definitions for inflammatory conditions of the pouch that could accelerate our efforts in clinical care and research. We also reviewed the best available evidence for managing pouchitis and other inflammatory conditions of the pouch to help clinicians improve patient outcomes after IPAA and assess gaps in our evidence and future directions for research.

PW: Is there anything else you would like to mention?

The multiple new therapies and strategies available make this an exciting time to be involved in the care of patients with IBD, specifically with IPAA. As we embark on new research, a major clinical focus, given our available evidence, should be tailoring therapies to individual patients and their symptoms, such as finding the minimally effective antibiotic dose or the appropriate advanced therapy. A rational plan about the driving symptoms and presentation for each patient, rather than a one-size-fits-all approach, will go a long way to improving outcomes in this population.